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«Review Article Received: 02/04/2014 ABSTRACT Revised: 19/05/2014 Accepted: 28/05/2014 Dermatological diseases, besides involving the skin and its ...»

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Oral Manifestations of Dermatological Disorders.

Yasmeen J Bhat*, Saima Aleem, Iffat Hassan, and Sheikh Manzoor.

Department of Dermatology, STD & Leprosy, Government Medical College, Srinagar- Kashmir University,

J&K, India.

Review Article

Received: 02/04/2014 ABSTRACT Revised: 19/05/2014 Accepted: 28/05/2014 Dermatological diseases, besides involving the skin and its appendages may also involve the oral cavity. The lesions of oral *For Correspondence cavity in dermatological disorders deserve special attention, considering that they may be the presenting clinical feature or the Department of Dermatology, only sign of these disorders. Moreover, oral mucosal lesions in skin STD & Leprosy, Government diseases can be life-threatning and also affect the quality of life in Medical College, Srinagar- terms of pain, discomfort, social and functional limitations. Various Kashmir University, J&K, dermatological disorders of diverse etiologies like infections and India. genodermatosis are associated with oral lesions but pemphigus vulgaris, lichen planus and candidiasis are the most common ones.

Keywords: oral, dermatology, Oral mucosal lesions may present to a dermatologist as well as a disorders. dental surgeon, thus improving the knowledge about them in both the settings will strengthen and enhance interdisciplinary and multisectoral approach and lead to better management of such patients.


Oral cavity encompasses a diverse group of anatomical structures, including teeth and oral mucous membranes. An oral mucosal lesion (OML) is defined as any abnormal change or any swelling on the oral mucosal surface [1]. It may be a result of local pathology or secondary to other systemic disease, including those of skin. In oral medicine, dermatological diseases have significance as OML may be primary clinical feature or the only sign of these disorders. A prevelance of 35% of OML in patients affected with dermatological conditions has been observed. Various groups of dermatological diseases associated

with OML are as follows:

 Infections  Vesicobullous disorders Lichen planus and other lichenoid disorders  Collagen vascular diseases  Vasculitic  Genodermatosis  Miscellaneous Pemphigus vulgaris, lichen planus, candidiasis and recurrent apthous ulcers were the most frequently diagnosed conditions [2,3].

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Herpes simplex Herpes simplex is caused by the herpes simplex virus(HSV). There are two major antigenic types, of which type 1, is classically associated with oral mucosal lesions. Primary infection is often subclinical [4]., When clinical lesions develop, herpetic gingivostomatitis is the most common clinical manifestation.

Most cases occur in children and begin with fever, malaise and excessive dribbling. The gums are swollen and bleed easily. Vesicles presenting as white plaques and ulcers with a yellowish pseudomembrane are seen throughout oral mucosa [5].

Recurrences occur in 30–50% of cases of oral herpes and do not affect the buccal mucosa, but labial lesions are common [4].

Varicella zoster virus The varicella zoster virus (VZV) is the cause of both varicella and zoster.

Varicella After an incubation period of 14–17 days, fever and malaise, is followed by the development of papules in crops which very rapidly become clear, unilocular vesicles. In 2–4 days a dry crust forms, soon separates and heals without scarring. Similar vesicles are common in the mouth, especially on the palate, and are occasionally seen on other mucous membranes [6].


The first manifestation of zoster is usually pain, followed by onset of eruption comprising of closely grouped red papules, rapidly becoming vesicular, in a dermatome. Mucous membranes within the affected dermatomes are also involved. Zoster of the maxillary division of the trigeminal nerve produces vesicles on the uvula and tonsillar area, whilst with involvement of the mandibular division; the vesicles appear on the anterior part of the tongue, the floor of the mouth and the buccal mucous membrane. In orofacial zoster, toothache may be the presenting symptom [7].


Herpangina is a specific infection, caused by group A coxsackieviruses of types 2, 3, 4, 5, 6, 8 and 10 and group B type 3, mainly affecting children. Fever of sudden onset, is followed, by sore throat and dysphagia. Up to 15 or 20 tiny vesicles, 1–2 mm in diameter, with a vivid red areola, develop on the pharynx, tonsils, the pillars of the fauces, the uvula and soft palate. They erode to leave ulcers, which heal in 4 or 5 days.

Hand, foot and mouth disease

The characteristic syndrome, seen in children, has usually been associated with coxsackie A16, but outbreaks have been caused by A5, A10 and human enterovirus 71. The disease usually presents as painful stomatitis. The oral vesicles are large, irregularly distributed over the palate, buccal mucous membrane, gums and tongue and ulcerate rapidly. Characteristic skin lesions are small, pearly grey vesicles with a red areola, most commonly occurring on the sides or backs of fingers and toes [8].

Oral hairy leukoplakia

This is an AIDS-associated lesion presenting as white plaques on the sides of the tongue occurring as a consequence of an opportunistic infection with EBV. It is also reported to occur in patients receiving immunosuppressive therapy and occasionally in immunocompetent individuals [9]. It presents as a white patch, usually seen on the parakeratinized mucosa of the tongue, frequently bilaterally. The lesions are corrugated or have a shaggy or hairy appearance, mostly symptomless [10].

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Skin disease may provide the first suspicion of the diagnosis of HIV infection and is also a prognostic indicator of the development of AIDS and overall survival [11]. Acute primary HIV infection presents clinically as a viral exanthem like illness 1–6 weeks after exposure. Transient intraoral redness, xerostomia, erosions and ulcers, candidosis and salivary gland swelling are all described [12].

Dermatological manifestations of HIV infection are diverse consisting of infections, inflammatory disorders and malignancies. Oral symptoms and signs are also common in established HIV infection [13].

Oral candidosis is very common in HIV-positive individuals and almost universal in AIDS [14]. HSV infection is common in and around the mouth. Hairy leukoplakia has emerged during the HIV epidemic [13]. Just over 1% of HIV-infected individuals have oral HPV infection. Distressing mouth ulceration occurs frequently. Candida, Pseudomonas and Staphylococci, causes severely symptomatic perioral ulceration complicated by pain, bleeding and inability to feed [15]. A necrotizing ulcerative stomatitis has also been described26 as has cancrum oris (noma) [27]. Severe periodontal disease is also not unusual [13]. Kaposi’s sarcoma occurs frequently in the mouth, often the palate. It appears as red patches, plaques or nodules.

Other problems that can affect the oral cavity include petechiae from thrombocytopenia, hyperpigmentation and oral labial melanotic macules [18], oropharyngeal cancer [19], lymphoma, and the side effects of radiotherapy and drugs. IFN, foscarnet and zalcitabine can cause mouth ulceration [20,21].

Oral candidosis Candidosis is an infection caused by the yeasts of the genus Candida. Superficial infections of the mucous membranes and skin are most important. Mucocutaneous candidiasis has a wide spectrum of clinical presentations [22]  Acute and chronic pseudomembranous candidosis (oral thrush;) [23] characteristically presents as a sharply defined patch of creamy, crumbly, curdlike white pseudomembrane, which, when removed, leaves an underlying erythematous base.

 Acute erythematous candidosis (‘antibiotic sore tongue’) [24] is characterized by marked soreness and denuded atrophic erythematous mucous membranes,particularly on the dorsum of the tongue.

 Chronic erythematous candidosis ( denture stomatitis) [25] is seen in denture wearers and children wearing orthodontic appliances, in the form of soreness.

 Chronic hyperplastic candidiasis (Candida leukoplakia) [26] occurs in form of very persistent, firm, irregular white plaques.

 Chronic nodular candidosis is a rare form, with cobbled appearance of tongue.

 Angular cheilitis (angular stomatitis; perleche) [27] presents as soreness and cracking at the angles of the mouth.

 Median rhomboid glossitis [28] is characterized by a diamond-shaped area on the dorsum of the tongue with loss of papillae.


Is a chronic sexually transmitted infectious disease caused by Treponema pallidum. In primary syphilis besides the characteristic genital chancre and inguinal lymphadenopathy, extragenital indurated ulcers may be found on the lips, tongue and tosils as a result of kissing, cunnilingus or fellatio.

The secondary stage of the disease is characterized by recurrent activity of the disease, with mucocutaneous as well as systemic manifestations. The most commonly observed clinical presentation (80%) is a generalized, non-pruritic papulosquamous eruption. Mucosal lesions range from small, superficial ulcers that resemble painless aphthae to large gray plaques or oval mucous patches, which coalesce to form ‘snail-track’ ulcers. Sharply defined, round or oval lesions devoid of papillae on tongue and split papules at the oral commissures are also seen.

Late syphilis has variable range of manifestations. Approximately one-half of patients with tertiary syphilis have “benign” late syphilis with the development of gummas. Gummata attack the palate, with tissue destruction that may lead to loss of tissue and scarring. They may also cause diffuse interstitial glossitis, with fissuring and necrosis.

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Another deformity, not so characteristic, is the ‘mulberry molar’—usually the first molar—which has a flat, occlusive surface with only poorly enamelled rudiments of the usual cusps.

Leprosy Leprosy is a chronic infectious disease with prominent involvement of the skin and nerves that is caused by the bacillus Mycobacterium leprae. There is a wide spectrum of clinical findings in leprosy Lesions of oral mucosa occur as papules on lips and nodules on palate (which may perforate), uvula, tongue and gums. The upper incisor teeth loosen or fall out [32].


Leishmaniasis encompasses a spectrum of chronic infections caused by protozoans Leishmania and transmited by sandflies from the genera Phlebotomus and Lutzomyia. Cutaneous leishmaniasis usually begins as a small, well-circumscribed papule at the inoculation site. This lesion may slowly enlarge over several weeks into an ulcerated or verrucous nodule or plaque. After a time period ranging from a few months to more than 20 years, some patients infected with Leishmania spp. (most commonly L.

braziliensis; rarely L. panamensis, L. guyanensis ) develop mucocutaneous disease. Oral mucosal lesions range from edema and infilitration of the lips to perforation of the palate. Similar involvement of nose is also seen. In some patients, there is extensive loss of tissue in both the mouth and nose, causing a characteristic“tapir face” known as espundia [33,34].

Vesico-bullous disorders Pemphigus vulgaris The term pemphigus describes a group of chronic autoimmune skin diseases characterised by the loss of cell–cell adhesion and widespread mucocutaneous blistering [35]. Essentially all patients with pemphigus vulgaris develop painful erosions of the oral mucosa. 50 to 70% of patients present with oral lesions and precede cutaneous lesions by months or may be the only manifestation of the disease. These painful erosions most commonly seen on buccal and palatine mucosa are of different sizes with an irregular ill-defined border and extend peripherally with shedding of the epithelium. The lesions may extend out onto the vermilion lip and lead to thick, fissured hemorrhagic crusts [36].

Paraneoplastic pemphigus

A distinctive form of pemphigus has been described in association with a variety of underlying neoplasms most commonly B-cell lymphoproliferative disorders but also thymoma, sarcomas and carcinomas37 and with the use of fludarabine chemotherapy [38]. Patients have severe mucosal erosions and polymorphous cutaneous signs [37].

Mucous membrane pemphigoid

A chronic blistering disease of the mucosa that may involve the skin, and usually results in permanent scarring of the affected area, particularly the conjunctiva. Oral lesions occur in the majority of patients. In the mouth, vesicles or small blisters, which remain intact for some time, may be seen and when erosions form they are persistent and extensive. Desquamative gingivitis with eroded bleeding gums.

Adhesions may develop between the buccal mucosa and the alveolar process and around the uvula and tonsillar fossae [39].

Epidermolysis bullosa

Inherited epidermolysis bullosa (EB), the prototypic mechanobullous disease, is characterized by the development of blisters following seemingly minor or insignificant trauma or traction to the skin [40].

Recurrent blisters, erosions, ulcers and scarring of mucous membranes including oral cavity is seen along

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Connective tissue disorders Systemic lupus erythemotosus.

A systemic disease characterized by multisystem organ inflammation, most commonly the skin, joints and vasculature, and associated immunological abnormalities. Mucous membrane lesions occur in 26% of cases, usually on the palate (82%), buccal mucosa or gums, in active phases of the disease [42,43].

Lesions start as small erythematous or purpuric areas, which break down to form shallow and sometimes painful ulcers, with a dirty yellow base and surrounding reddish halo. Hyperkeratotic lichen planus-like plaques on the buccal mucosa and palate occur in 9%. The lips show slight thickening and roughness and redness, sometimes with superficial ulceration and crusting. Healing occurs with some scarring [42].

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